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Early clinical management of acute upper gastrointestinal bleeding: a UK multisociety consensus care bundle

Abstract
Introduction Medical care bundles have been shown to improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed to develop a multi-society care bundle centred on the early management of AUGIB for national implementation to improve standards of care.

Methods Under the remit of the British Society of Gastroenterology (BSG) Endoscopy Quality Improvement Project, a UK multi-society task force was assembled to produce pragmatic evidence and consensus-based care bundle detailing key ward-based interventions to be performed within the first 24 hours of presentation with AUGIB. A modified DELPHI process was conducted with expert stakeholder representation from BSG, Association of Upper Gastrointestinal Surgeons (AUGIS), Society of Acute Medicine (SAM) and the National Blood Transfusion Service. A formal literature search was conducted on major databases and international guidelines reviewed. Evidence was appraised using the GRADE quality framework. Once working groups had formulated initial evidence-based statements, a face-to-face meeting with anonymised electronic voting was arranged to evaluate consensus with statements and care bundle items. Consensus was defined as reaching 80%+ agreement on each statement, with revisions and up to three rounds of voting permitted. Accepted statements were eligible for incorporation into the final bundle after a separate round of voting. The final version of the care bundle was approved by corresponding stakeholder and patient groups.

Results Consensus was reached on 19 recommendation statements; these culminated into 14 corresponding care bundle items (figure 1), enveloped within 6 management domains: Recognition (to facilitate early diagnosis), Resuscitation, Risk assessment, Rx (Treatment), Refer and Review (post-endoscopy care).